CIHM 
Microfiche 
Series 
(Monographs) 


ICMK 

Collection  de 
microfiches 
(monographies) 


Canadian  Institute  for  Historical  Microroproductions  /  Institut  canadien  de  microieproductions  historiques 


\^^y      I  ^J^  ^^  ^^ 


Technic^i  ;;ncl  BiDliographic  Notes  /  Notes  techniques  et  bibliographiques 


Tie  Institute  has 
copy  available  for 


■ipied  i  ,  obtain  \'~:e  best  original 
'  ri;-,  Fca'ures  of  this  copy  which 
may  be  bibliographicaiiy  iniiV'^.  whicn  may  alter  any  of 
the  images  in  the  reproduction,  or  which  may 
significantly  change  the  usual  method  of  filming  are 
checked  below. 


n 
n 

D 
D 

n 
n 
n 


Coloured  covers  / 
Couverture  de  couleur 

Covers  damaged  / 
Couverture  endommagee 

Covers  restored  and/or  laminated  / 
Couverture  restauree  et/ou  pelliculee 

Cover  title  missing  /  Le  titre  de  couverture  manque 

Coloured  maps  /  Cartes  geographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)  / 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations  / 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material  / 
Relie  avec  d'autres  documents 

Only  edition  available  / 
Seule  edition  disponible 

Tight  binding  may  cause  shadows  or  distortion  along 
interior  margin  /  La  reliure  serree  peut  causer  ce 
I'ombre  ou  de  la  distorsion  le  long  de  la  marge 
interieure. 


I      j    Blank  leaves  added  during  restorations  may  appear 

within  the  text.  Whenever  possible,  these  have  been 

omitted  from  filming  /  II  se  peut  que  cerlames  pages 
blanches  ajoutecs  lors  d'une  restauration 
apparaissent  dans  le  texte.  mais.  lorsque  cela  etait 
possible,  ct  J  pages  n'ont  pas  ete  filmees. 


L'Institut  a  microfilme  le  meilleur  exemplaire  qu'il  lui  a 
ete  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire qui  sont  peut-etre  uniques  du  point  de  vue  bibli- 
ographique,  qui  peuvent  modifier  une  image  reproduite, 
ou  qui  peuvent  exiger  une  modification  dans  la  metho- 
de  normale  de  fiimage  sont  indiques  ci-dessous. 

j         Coloured  pages  /  Pages  de  couleur 

I I    Pages  damaged  /  Pages  endommagees 


D 


Pages  restored  and/or  laminated  / 
Pages  restaurees  et/ou  pelliculees 


□    Pages  discoloured,  stained  or  foxed  / 
Pages  decolorees,  tachetees  ou  piquees 

I j    Pages  detached  /  Pages  detachees 

I/I    Showthrough  /  Transparence 

I      I    Quality  of  print  vanes/ 

1    Qualite  inegale  de  I'impression 


n 


D 


Includes  supplementary  material  / 
Comprend  du  materiel  supplementaire 

Pages  wholly  or  partially  obscured  by  errata  slips, 
tissues,  etc.,  have  been  refilmed  to  ensure  the  best 
possible  image  /  Les  pages  totalement  ou 
partiellement  obscurcies  par  un  feuillet  d'errata,  une 
pelure,  etc.,  ont  ete  filmees  a  nouveau  de  fa^on  a 
obtenir  la  meilleure  image  possible. 

Opposing  pages  with  varying  colouration  or 
discolourations  are  'ilmed  twice  to  ensure  the  best 
possible  image  /  Les  pages  s'opposant  ayant  des 
colorations  variables  ou  des  decolorations  sont 
filmees  deux  fois  afin  d'obtenir  la  meilleure  image 
possible. 


D 


Additional  comments  / 
Commentaires  supplementaires: 


This  Hem  is  filmed  at  the  reduction  ratio  checked  belov» , 
Ce  document  est  filr  -e  au  laux  dn  reriuriinn  mriir 


10x 


14x 


lini  lo  r  i.H/i 


18x 


12x 


16x 


20x 


22x 


26x 


30x 


24x 


28x 


The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

J.J.  Talman  Regional  Collection 
D.B.  Weldon  library 
University  of  Western  Ontario 

This  title  was  microfilmed  with  the  generous 
permission  of  the  rights  holder; 

Alan  D.    Chesney 


L'  exemplaire  filme  fut  reproduit  grace  a  la 
generosite  de: 

J.J.  Tainan  Regional  Collection 
D.H.  Keldon  Library 
University  of  Western  Ontario 

Ce  titre  a  ete  microfilme  avec  I'aimable  autorisation 
du  detenteur  des  droits: 

Alan  D.    Chesney 


The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility  of 
the  original  copy  and  in  keeping  with  the  filming 
contract  specifications 

Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on  the 
last  page  with  a  printed  or  illustrated  impression,  or 
the  back  cover  when  appropriate.  All  other  original 
copies  are  filmed  beginning  on  the  f'rst  page  with  a 
printed  or  illustrated  impression,  and  ending  on  the 
last  page  with  a  printed  or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche  shall 
contain  the  symbol  -^(meaning  "CONTINUED"),  or 
the  symbol  V  (meaning  "END"),  whichever  applies. 

Maps,  plates,  charts,  etc  ,  m,ay  be  filmed  at 
different  redLiction  ratios    Those  too  large  to  be 
entirely  included  m  one  exposure  are  filmed  begin- 
ning in  the  upper  left  hand  corner,  left  to  right  and 
top  to  bottom,  as  many  frames  as  required    The 
following  Qia  ;rams  illustrate  the  method 


1 

2 

3 

Les  images  suivc   ies  ont  ete  reproduites  avec  le 
plus  grand  soin.  compte  tenu  de  la  condition  et  de 
la  nettete  de  I'exemplaire  filme,  et  en  conformite 
avec  les  conditions  du  contrat  de  filmage. 

Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimee  sont  filmes  en  commen^ant 
par  le  premier  plat  et  en  terminant  soit  par  la 
derniere  page  qui  comporte  une  empreinte  d'lm- 
pression  ou  d'lllustration,  soit  par  le  second  plat, 
selon  le  cas.   Tous  les  autres  exemplaires  origin- 
aux sont  filmes  en  comimengant  par  la  premiere 
page  qui  comporte  une  empreinte  d'impression  ou 
d'lllustration  et  en  terminant  par  la  derniere  page 
qui  comporte  une  telle  empreinte, 

Un  des  svmboles  suivants  apparaftra  sur  la 
derniere  image  de  chaque  microfiche,  selon  le  cas: 
le  symbole  -*  signitie  "A  SUIVRE",  le  symbole  V 
signifie  "FIN" 

Les  cartes,  planches,  tableaux,  etc.  peuvent  etre 
filmes  a  des  taux  de  reduction  differents    Lorsque 
le  document  est  trop  grand  pour  etre  reproduit  en 
un  seul  cliche,  il  est  filme  a  partir  de  Tangle 
superieur  gauche,  de  gauche  a  droite,  et  de  haut 
en  bas,  en  prenant  le  nombre  d 'images 
necessaire    Les  diagrammes  suivants  illustrent  la 
methode 


1 

2 

3 

4 

5 

6 

MICROCOPY    RESOLUTION    TEST    CHART 

ANSI  ond   ISO  TEST  CHART    No    2 


1.0 


I  2  8       jllll  2.5 


S32 


1^ 


2.2 


I.I 


1.25 


1    2.0 

I-    ^ 

1    1.8 

1 

1.4 

1.6 

-lED  IIVMGE     Inc 

.A 

Studies  in  Liver  Function 


A 


A       M       til  I'  >  \  '■  \'.      Ml). 

K         M     \    In   --   II     \    I.  I,.       ju..        I'll. I). 

\  \i> 

I-.     (.,      k  '  1  W   X    I   l<  I.  I'..     Ml). 

i:  \i.  1 1  \iwKi-: 


Kr/'tniti-ii    from    The    Jvunial    ,/    the    AmcrUan    Medical    Assorialioii 

(),i.  ■•/.  i>Ji4.  r„t.  I. Mil.  rr-  i^'<  i^" 


CorYRir.iir,    1914 

Amkricax    MfDicAL    Association 

i  ivi     III  sniiED   AM)    Thirty  I'lVE   Noktm    Dearburn    Street 


STl'DIKS     IX     L1\ER     l-'CXCllOS  * 


A.    M.    CHESXKV,    M.]). 
i;.    IC.    MAkSHALI.,   Jr.,    ]',i.l). 

I-    <i.    KOWXTKI':!-:,    M.l). 
I'Ai.riMdH.i-: 


Tn  m-osnition  r,i  the  need  r,f  I.cllcr  criteria  for 
Jii<l,^in,i(  of  the  lu.u-tional  ca])aeity  of  the  liver  in  dis- 
ease, this  n!vesii,!,raii(,n  wa.s  nndertaken  to  determine 
(I  )  the  de,i,nee  and  Irequeney  with  whicli  functional 
clian-es  can  he  d.enionstrated  in  anatomically  diseased 
livers,  (ii  m  uhat  clinical  tvpes  of  liver  injurv  the 
lunciional  chan.-res  are  most  marked  and  (3)  thc"dia<--- 
noslic  and  pn.-ivislic  value  of  these  chauijes.  In  other 
words,  an  aliemi.t  has  heen  made  to  re-anl  the  liver, 
HI  disease,  1  rom  ;i  |ihysiolooic  point  of  view,  and  to 
stndv  Its  v.-irious  functions  with  the  hoiie  of  ascert.ain- 
m<^  us  liehavior  under  i)alli(ilo<,ric  conditions. 

Tin-  i-!-X(Tio.\  OK  Till-:  r.i\i:i<  ix  ui-ai.tii 
111  health  the  liver  has  three  \vcll-cstal)li,;lu'd  func- 
tions: 1.  I  he  .■;lvco,i,a.uic  function,  which  has  to  do 
wuh  carhohydrate  metaholism,  ami  consists  in  (a)  the 
conversion  of  the  monosaccharids  (dextrose,  levulosc 
and  -alactose)  int.,  oiyco<,ren  ;  ( /> )  the  temporary  stoi- 
.-i,^'e_ot  that  ,i,dyco-cn  as  such,  and  (ci  the  reconversion 
nt  It  hy  enzyme  activity  into  dextrose  as  needed  in 
the  hody.  2.  A  participation  in  nitro<Tenous  metabolism 
which  consists  m  the  conversion  of  certain  nitrojjenoiis 
liodies  (  amiiH. ma,  amino-.acids.  etc.).  into  urea.  ^  Tiie 
production  of  hile. 

h\  addition,  the  iivc^r  app.irentlv  plavs  ,a  p.irt  in  the 
piVKhiction   of  fil)rino<4en   and   .iiuithnmihin,  althoufjh 

•  Fr,.m   il„.    Mr,l,V_,l   riinic  <,f  thf  Jolnis  Hopkins  Hn.pit,,],  .md  fr„m 

•  Kc.c.l   li.f.ui'   thf   Sialic. 11   ,,n    I'ra.iiic   of    .\[,.IiriiH<    it    I),,.   SKiv  n,,!, 


il'i'  o.ninrtioi,  if  tlu'  latin-  liiiuiimis  uitli  tlio  liver  is 
""I    -"    ^u•ll   e>tabli,>lK-.l   as   ilio   WvA   ihivc   inf.uioiu.i 

TIIK    -I|-ST>    (i|     ll\i:!;    ir\(  tkiX 

Tli^-  lnl!r.ani-iesi.  l.aM,!  ,,i,  wcll-kiKnvii  plu-.iuin.MV- 
"i"'-l">ns  Mt  ilu-  liver  lia\c  hern  tinplovod  :        ' 

1.  ^■nhohyclratr  .l/,7,/.\,//,w;;.  -in  iln\  w.niK..-tion 
l^'o  tests  ),a\e  hem  emploved,  nanielv.  Strauss''  jevu- 
I'-e  Ii;m  .m.i  I'.a.ier-.^  yalariose  test.  The  l<,niier  eon- 
Msis  „,  the  iti-esti.,11  ,,f  loo  .uni.  ,,f  levulose  on  an 
'■iiipiy  Mfiniach  and  the  exaniinalidii  nf  the  tiriiie 
'-'"l^'l  'l"n.!o-  the  n,M  teu  h.ans  tn  deteianine  the 
'!",:'■'"''■  '■'.'■  ••'I'-^'i^-i'  "t  iIh'  siioar,  n-iii-  |-ehliiit,r\  and 
-eliuaiK.ll  s  tests.  Ilaner-s  is  similar  in  Strauss'  test 
^•xcvpt  llKU  ,^()  nn,.  of  j^alael.,.e  are  nsed  insiea.l  ..f 
1  H)-n,.  ,,f  Kvnl,,>e.  The  in-esiinn  ,,t  these  sv.,ars  in 
'lie  aninnn,.  ,„dieated  dnes  „,,t  tvsnlt  in  their  ai.pear- 
•nire  I'l  the  innie  ni  la.rnial  indi\  idiials.  aemrdinn  to 
"trails.,  Jin.,,-  anpearaiiee  in  ;h,  ,i,i„e  is  due  i")  a 
de.rease  ni  injeranei  I'nr  these  snh,|  :,„,-es,  ii-dj,ati\e 
"t  d.-eieased    Inneticiial  <aMaeil\   .,i'  the  lixei-. 

2.   -\!ti;„,, 'lions  Mrt.ihnrsm       in   relation   u,  viiv,-^ 
vn.Mis    nietaluahsin    and    ii\er    Inneti-.n    a   siu<!v   of   the 
nnr,,-e„   ,,arlitinn    in    the   hlood    and    in   the   urine   has 
'"■'."    '"■".''■■      "    "h^   liver   ennverts   the  anini.mia   and 
■'""""-'"■"'-  "»   tin-  li!o,,d  into   inra.  then   it   nii-ht   he 
•■xiHvle.l  that  in  hver  initn-v  we  sh,,nld  Inid  a  deerease 
nilhc  urea  ])ereenta,t;-e  ..t"  the  K.ta!  iKin-protein  nitroi^en 
"[  tiu  h.ood  and  an  nierease  in  the  ainino-acid  nitro-en 
"'  "'^'  '''"'"'•  '^'"'i-  i'i  i1h'  mine  ne  nn-ht  expeel  !o  Imd 
■■}    <lcrrcase    m    tlu-    relati\c    amnuni    of    nrea    with    an 
increase  in  ihe  ammonia  and  amiiio-aeids.     (Tin    \  ie>' 
liiat    tile   li\c.r  i.s   n,,t    wholly   responsihle   for  the   eon- 
M'rsion  (,1  tlie  ammonia  and  aniino-acids  of  the  hloo.l 
into  itaa  has  reeentlv  reeeived  supDort  from  the  woiT 
"f  l'<'hn    and  \  an  .^Ivke'  and  of  |-iske  and  Sumner.'') 
V    I  '"!'iliii,h/ri!.    -  \\   ha~    heen  maintained   h\-   nianv 
"hsu-\ca-s    that    the    i    >senee    of    nrohilinoiren'  m    the 
ntnie     is    mdieativ.      of    liver    disease.       I -rohilino.rc.,. 


'■„'■•    "','•''''''■    '""'■    \\>l'"sd,,..    Vim.   vvvii,   75/-. 
.^.    l-chii:    .l,,ur.    Ri„l.    CIhtm.,    f>lj     ^i     fT 

.\>..m„l.,.,„n.  al,Mr.,  TuK  .t.„  kn...    A.  M.  A     .April   1  ?.' I'lh:  ,, '  It.,'"" 
.'.    I  i>ki-  .,11.1    .Siunncr:   Jour,    ilinl.   C'lipni.,    MH,   xyiii,  J85.' 


ilLtcTiiniiaticiis  utru  ina-lc-  in  the  niajoritv  of  ca-us.  l>ut 
•  lu-mj;  to  ihr  ai-pcaraiux-  of  tlio  ivrciit  coniiJrc-lR'tiMvc 
W'jrk  of  Wilhur  and  .\(l.li>,'^  and  to  our  own  unsatis- 
factory rosulls,  tliL'si'  ik'tcrniiiiations  were  discon- 
tinufd.  ■i'liosc  in\fstis;ators  showed  conclusively  lliat 
(il)scrvations  on  a  sinjjlo  or  a  twcnlv-four-hour 'speci- 
men liave  no  significance,  since  tren'iendous  variations 
occur  from  day  to  day,  an<l  that  onlv  where  rejieated 
o1)^er\atl()n~  are  made  o\er  a  jieriod  of  at  least  two 
week-<  and  liien  only  wiien  control  studies  of  the 
urohilin  content  of  the  feces  have  heen  made  to 
exclude  lilood  destruction  as  a  factor  in  the  iiroduction 
of  iiro!iilino,i,an  can  lindinRs  he  accepted. 

4,  yy'"-/;;ry/(V/.— -There  is  e\  idence  to  show  that  the 
hvrr  1-  .active  in  the  formation  of  lihrinoijen,  and 
\\hijiplc'  ha-  <ui:,ye-.ted  that  the  determination  of  the 
amount  jnocnt  in  oxalated  iilaMua  niav  he  used  as  an 
itiiKx  of  li\er  function. 

.-.  /.//^(;\,-.— Whipple--  has  al<o  su^.tjested  that  the 
e-lmialidii  of  the  lipolytic  activitv  of  the  hlood  niav 
constitute  a  te-t  of  li\er  fmicti(jn' 

<'k  Pii:iiolt<^lr,u-lil,irHit/hiL'ii'.--'l'hi-^  (IruLf  was  Intro- 
ducid  liy  l^:(.'vl;lr^c.  ilnrwiiz  and  I '.loon'ifield"  as  a 
tcM  fiir  hep.atic  function,  and  clinical  .studies  hv  them 
.'iiid    Mmultaneou-    experimental    studies    liv    \Vhi 


and  cd-w 


r!<er' 


il)ple 
lov.ed  that  a  normal  excretion  could 
he  e.-.laj'hslKd  and  thai  ni;iny  liver  injuries,  particu- 
larly of  ~e\ere  -rade-.  were  a-HH'i.ated  with  a  decide.] 
decrease  m  the  phenoltetrachkirphthalein  output,  h'ur- 
ther  siudie-  with  this  test  have  heen  carried  on. 

7.  I'll'nn.'lylir  l\-niiciil.—  \)v.  ( ioodpastm-e  of  the 
p.alholo'.;!,-  <t  iiV  was  already  intere.-ted  in  the  presence 
ot  a  lihn;iol\iic  ferment  in  the  lilood  in  li\er  cirrhosis 
when  this  work  wa-  undertaken,  .'■^amples  of  ])lood 
iiom  ;i!i  our  )iatienls  were  sulimi'ted  to  him  for  studv. 
and  ihrou-h  lii-,  courts -y  we  jjresent  the  results  of  his 
studks.  dei.-'ds  of  which   will  ai)pe,ar  later.     The   fer- 

(..   Wnin.r,    K.    I.      ,,M     \  Mis,  Tl.om;,s:   TroIiiliM:    Its  Cli,,:.,,!   SiKtiin- 

-.    Whiyi.U-  ::ru\   llnrwit^:  Jofr.  Expcr.  Mel.,  I'M],  ^i;i,  i.,,;.  Wl.ipplc. 

I  Kp.it. c    (,rr,i.s,s     Arch.    Int.    Med..    M:,rcl,,    I'UJ,    p.    M,S       Whip  Ic 

-Mmsu,,  „„,i    v,j;h,,.,i..  Hull.  .r„h„s  Hopkins  ii„sp.,  iM.i.  xxiv.  j"    "    • 

•       .V'"'','!','.-^';'''""    '""1    PiiKht.-.I:    Hull.    (nhn>    Hopkins    Uom.      lon 
Am.   Jnnr.    Physiol.,    j'lH,   xxxiij.    ijp  >>iniji,i.. 

^'1.   K.miilr.H,    llnr.ntz   .in.l    liloonUicKl :    liull.    Johns    Hopki.is    I[o«p 


I'M,! 


iiu-nf  Is  spcril'ic  for  lihriii,  ,\nv~.  not  att;u-k  lil)rinn./.ii 
aiKl  Is  (Icsiroyei!  l>y  iKatiui,'  tn  r(,  C.  {  \,U.X  !•".). 

-MI-.TIlilDS    AVI)    \(i|'\I.\I,    LIMITS    (i|      IT.S  IS 

/"■'•'•■'•"■  I   li.s    icsl    \\,l>    ClllpKHCU 

aa-onliii','  to  the  iiK-lliod  dcscnhi'il  hv  l^nvntrcc.  I  fur- 
\vitz  aiu!  illoonificld.  details  of  uhirli  arc  ijivcn  in  full 
m  tlic'ir  inililication;'  'I'lu'  iouLP  limit  of  normal  rxciv- 
lion  Is  considi'tvd  to  he  M)  ,KT  run.  ir.  fortv-ri-lu 
iioiirs  :,t\vv  ilu'  mtravcnoiis  injection  of  4()()  in<;.' of 
the  sul,si;i„cc.  In  health,  lihciu^ltctrachlorphthalun  is 
Iiracticallv  ne\er  excreted  in  the  urine  after  iiiieclion 
ot  siieli  amounts. 

/■//')•///«,/,•//.-  The  heal  coa-tilatioii  lueihod  as 
(Ic-scnhed  hy  Whii.i.le''  was  uied  in  thc-e  determina- 
tions, and  \a!ues  helow  .i5()  <,nii.  per  hundred  c.c.  were 
rei:a'"ded  as  ahiiormai. 

/.//'(M-.-.^^l  Vt^nuinalions  of  the  liiiolvtic  acti\ilv  of 
the  hloo.j  were  made,  usinij  I.oevenhart'.s"  iiutiiod. 
wliicli  eonsisis  i,i  ihe  deterniiuation  of  the  total  acid' 
liroduclion  of  the  hlood  when  exposed  to  known  (|uan- 
titus  .,f  etiiyl  hutyrate  ;il  ,v  C.  i'»S.f)  I-'.),  'j-hc  result 
IS  expressed  .as  the  inimher  of  cuhic  centimeters  of 
tenth-normal  acid  produced  hv  1  c.c.  of  plasma  and 
0.2>>  c.c.  ethyl  hutyrate,  diluted"  to  4  c.c.  and  allowed  to 
react  h>r  from  tweutv  to  twenly-four  hours.  The 
upper  limit  (jf  normal  has  heeii  taken  to  he  0.40  c.c. 
of  li  nth-normal  acid. 

■//',•  XHrrarn  l^u-titioii  in  Ihr  lilond  and  [Jriiic— 
Ihe  total  iioi;-proiein  nilrouen  of  the  hlood  was  e<ti- 
nialed  hy  the  micm- Iv  jel,l;i!d  inelhod  of  Inhn  ,and 
Deuis.'-^  with  sh'-ht  m.Mliiic:. lions.  ;is  .sU!'.^e>ted  hy 
I'r.  P..  ]!.  'luriier.''  The  urea  iierccnta.tjc  of  the  total 
nou-proteiu  iiitroy:^.,,  of  ,|,^.  i,|,,„(i  ^^..,^  determined  hy 
Marshall's"  method.  utiliziiiLf  sov  hcaii  urease,  and 
\ahics  helow  40  per  vcul.  have  hcen  regarded'  as 
ahnormal. 

The  amino-;icid  determinations  were  m.ade  hy  \'an 
.^l\ke's^  •  method.  .\s  yel,  data  coucerninij  the  a.mounl 
<^_f_J>'ii''i"-;i'-"i'l>     present    in     the    hlood    of     normal 

10.  Whipple:    Am.   .lour,    Plivsiol..   l')U,   s.sxiii.    50 

U.  I.i.evenli.-irt:  Am.   jfiur.   I'hvei.il.,   l'>0_',  vi.  \m 

1-'.  I'oliii  :rn.|    Drills:   Jniir.    liiol.  Clu-ni.,   mi^    xi  '  S '7 

1.1.  Tlicse   i,io,lilR.iii,,i,s   will    l,c   .i,-sirilic.l    stio'rtlv"  \>v    Dr     •J-nmer 

14.  .Marsh  ill:    loi.r.    ili.il.    (  lu'iii.,    I'M.t.   nv.   4X7  '       ' 

1.-.  \  ui    Sl>:<c:    .Iniu.    II;. ,1.   Chciii.,    lyiJ,    xii,    }'>'j 


J. 


iiiili\  i(lii,il>  are  M.-aici.,  Imi  iiuiu  a  sliuly  of  pnticnts 
wliK  well'  praelicallv  ni-iiiial.  ,i  m^.  per  luimlixcl  c.c. 
nf  .-criim  lia<  I)crn  iIk.'  value  resj^anlc!  n-  iIr-  \\])ycv 
limit  III   niirinal  i>>v  ihr  tree  aiiiinn-a'.-iil  iiitroueii. 

I  !:e  liilal  i;iirn!L;eii  nt'  tl'>  iii'iiie  was  ileteniiiiied  on 
iwentv-Inur-hniir  -.|n.eiiiKiis  eolleeted  umitT  Idlnol  hv 
the  Kielilalil  <  iiinitiiiy  iiietluHl,  the  urea  he  M;  rsliall's'" 
and  the  amiiiMiiia  h\  l-nljirs''  methixh  The  (iisirihi 
''""  "f  t!ie  uriiiar\  niirdiaii  helueui  tirti  ami 
aiiiiiKiiiia  lia^  heeii  shnwn  tn  he  (lei)enileiit  (Hi  the  total 
excretion  (jI'  nitr(),<,'en.  The  noianal  limits  of  the  vari- 
olic iiitrnyeiiou-  i-niisiiuKnl-  (jf  the  urine,  with  \arvin,t; 
lc\e]-~  ot  nitroi^en  exerelion.  are  therefore  li.ard  to 
deliiu'  sliarpl)-.  I  iouever,  one  can  jirohalilv  safelv  eon- 
i-liide  lliat  with  a  nrina.rv  nilro'^'ui  e\i  I'etioii  of  10  <,mii. 
or  more,  the  lower  limit  for  nrea  mlroi^n'ii  is  SO  per 
rent,  and  tlie  upper  limit  for  ammonia  nitrr),<;[cii  is 
.^  pi  r  cult.,  while  with  .i  nitro"en  excretion  (jf  from 
.-^  to  10  i,'!!!.,  tin  l(jw.;r  limit  for  nrea  is  70  jier  cent, 
and  the  ujiper  limit  for  ammonia  is  S  ]>er  cent. 
1-iirllKrmore.  exi'es.si\e  ;iciil  prodtu'tion  in  the  ortjan- 
ism  is  .-(ccompanied  with  a  lowering,'  of  the  iire.a  per- 
centa,<,re  and  an  increase  in  the  ammonia  perceiitac:e. 
The  free  amino-acid  in  the  urine  was  determined  hv 
\  an  .'^lyke''^''  iiielhod.  and  1.5  per  cent,  has  heen 
adopted  as  the  upper  limit  of  normal.  iMitiire  work 
ma\-  chaii'H-  these  xrihies. 


sr.MMAK'i     ol"    I-1M)IM,S 


rort\  -li\e  cases  have  heen  studied  in  this  series,  in 
ne.irly  all  of  wliicii  sonie  ahnormalitv  of  the  liver  was 
ihouy^ht  to  he  jiresetit.  ."^ome  of  the  cases  called  cir- 
rhosis were  certainly  not  far  advanced,  and  in  some 
instances  it  ajipeared  that  the  dia.i,niosis  was  not  deti 
nilc,  ditterences  in  opinion  heiiii,'  fre(|uentlv  encoun- 
tered. (  )n  account  of  lack  of  space  the  details  of  the 
case.s  are  not  t,Mven  here,'''  hut  a  summary  of  the  results 
ohtaiiied  is  !,d\en  in  'I'.ahle  1. 

Column   1   sIkmvs  total  iiumher  of  tests  made.  Col- 
umn 2  the  total  mtmhcr  of  ptisitive  results,  while  the 


16.    ^^,-lrsll.^!l:   Jour.    Hii)l.   Clicm.,   '913,  xiv,  283;    .\v,   495. 

ir.    I'olin:   Ztsflir.   t.   phvsiol.  (hem.,   l'»nj,  xwvii,    161 

l.S.   y.iil    Slykc:    Jcnir.    ninl.    Clieni.,    I'Jl.',    .wi,    l.'l. 

I'.'.  I'imliiiKs  of  ;ill  tcits,  clinical  notes,  nccrnpsy  finilirRS  in  fal.il 
cases  togctlier  willi  a  iliscnssion  of  tlie  f'lnclinnal  linilin^s  appear  in 
ttie  article   in    tlie    Proceedings   of   tlie    .Society    of  American    Physicians, 


onui    tiqiiKs  iinlirau-  i he  !i.inilif-     •"  ,,    ;■■■,      r     r 
">  tin-  ,,arlia,Iar  ,liM.,-,...      '  "   '    ^^"''^'  '""'"'"^ 

'•>"ni   tl,i.   -al,k.   i,    ,,,|i   l,c   ,ev„   that    'hv    fnllnui,,..- 

:<-*f   ■•■I''  .iplihcl  111  the  tca-s  ill  4?  ca.cs  u-.M    ir 
>n  the  ttriia.  in  ,U  ca^o  uith    'I,;,         ^       7  " 

^«'";....l)at,s.2()ahi.ni,al7i„,;      '',      V'w/^ 

;',;7V""7''' '--"neMi^atu^ii.^./  .:,:{■;  ^ 

"l'H-li^li.uv..!aiia,idi,rn,li„.|i,,„,.f  ..„....,/,•    "^ 


Iir(i(hu-ti<in  of  more  tlian  ().+  ,-,c 


.,,,,1       '1  ,,    -  .    ,, "■"■     '"      ilMJIl.-     Ill  U.+    (•    r 

■""'■^  ■'''->•<>..->•.■.       IhrtM-eMluvof   /,■'.•/;„,/■,'.■,•   Z  ■  • 
'"■■"'  u.-i^  tc-u-,I   for  in  40  insfuKv^    an,!  I   ••    -" 

^'""f-hu-h    werenrrho..;  i\;,X      ,';7'V"'' 

;I>nwn,^onlv4an,hlK.la.ter2po-.itiv,     in,  it  '        'he 

/-<    -'v-k.tern,,ne,lin.^7.,.,.      The  „rea  nitn,.!.' , 
•■■'^   ''-"'•■".^••iHTeent.  of  ,h.  ,o,al   in  M  lu<Vnu-v^ 

;'v:"'';:: /""■"""  r^''- ''^'""' ^   ^'t-'-nJi -n 

>.   ■    "    -■    niMaiuas  and  ahnve  4  nit,-,  in    1.^   in^taiue. 
""    ''/"^    '""•'""■"    '"•'•"    -"/   annnnni.    in    flu        ■,, 

r>nte :::;::, o':;l!, :;;;-:,,  ,?::;-• '^ 
;;;;;- ,ntro..ii..o.,o:^';,;::;;:r;'Tln^;a;:: 

:-       lK;:,innioiiia    mtro^ni    a^o^e    5    p.reeiit.    in    l(i 

sui  iMtAcui  ,>a.vl  10.;ni.,an,I,,|  these.  4  ra^e. '.houe.1 
••i  "n-a  lutro^ui  i'ehne  7()  i.^- rmt    an,l   11      ,, 


'Y"-'t  o,   ,!h.  nriiu    wa-  un  .M.^ale,!  in  22  .as. .     ]9 
liita!  nilroirrn 


l>er   eent.    of    ihe 


•     '■    l:'Mss,i„I„.,|uereasfolious:   I 'h..,,.  ..,.,raeh  or 
•'"''•ili'i'i  Mn4u  t!  in  f, ,-,  .,,,11    ,       ■,•       ■ 

,,  _  .        ;  "1  ->\i'i   14,  [losiiu,.  ,„  ,,    ,,,  „,.j 

II.   poMu,.    ,„   ,  ,   nl.rino:,.,,,    j„    I,       ,,^j  j        . 
"I'.':V"'.  'i.  !'-uu,  ,1    2:  h!,rii,olvtir   f  .n,u  n     ii     1    ' 
l;-.n., n..,,.W,o.,i,Ml.  positive  in  2         'iVii 
'<'-P.M,u.,n2:nrean„ro,n,pen-..n,a,e,hI     ,4 


r«      c  "I"!  ■=■      ^  . 


in  u 


i 


«^      PI      o 


U 
g 

a 


fvi      ^»r»i      ^^fvj", 


■  -  =  =     c-     ecc 


I 


m 


O  3 


;<^-;>     ;s*     :;:;<: 


■nj32 

o 


«       —  v:       t^  .r.  ^f  - 


o-r'2  :-S  : 


'     :  :     ;  •  • 


14,  iMiHinr  ill  ^:  ai)|i!„,  njim-cii  i  Md.,.!)  in  14,  ]M.si- 
tivi'  111  10;  iii-(.;i  ].i;iviiit;iL.'x-  (  uriiu' I  in  14,  i '-itivc  in  .i  • 
:inini(,nM  j.c  nu;i;i-x-  Miriiu')  in  14.  jiomiuc  in  10 ' 
anniKMiitn.-.n  pciviiiM-c  (  nrin.  i  in  7,  jMiHlivr  in  ,-. 
.i/.\"(-|.'' (//,//  /iisiil/inriu-\\-  I'wcKi'  rnsc^  ,,''  in\-o- 
*ar<li:tl  inMilfK  iinrv  ^\  nv  Mn.lir.l.  I 'lunnlirlrarliloi- 
plHl'::Kin  .mdul  ,„  ,V.v.  j,,  .,  ,,,,^,  ^,„|,  ,  j.^^itivc 
l_'>wc-l  l)un-  IN  iHT  r.  ui.,  ;,n.l  in  nrinr  !()  e;,-t  .  N\itl, 
■^  I'"-itivis;  |il,rni,,-ci]  in  11  uii|,  1  ,„,.iiP,  c;  lipa..-  jn 
11  i:i-c-  witli  1  |..(i-iii\r:  iihriiiiilMir  icrnirnl  in  1> 
jK.HiivL'  in  noiu';  -.•il:K-tM.c  in  7,  p.i.itivc  in  none;  Icvu.' 
i<><v  m  ,•),  iM.~n:',c  li  ii,,;k':  uwu  nilroi,H'n  Denvnlriw 
(1)100(1)  111  ]2.  iH,sin\r  i-i  ],  in  xvliidi  (>  wire  ove-r 
.^1)  jaT  rrnt,.  au,l  ,i  nwv  t,i)  y,y  rint.;  aniin.,  nilni-cn 
(  Mdiiil )  ill  ').  ]„.siii\i.  i,i  7^ 

I  iu'  Innolicnal  iiijiirv  in  li\er  rinlm-is  i.  nl.itiwlv 
i;iv;i1cr  lli;in  in  clinHiic  pa.M.r  on^'stinn.  inr  a  Cdn- 
sKicrati.^n  nt  .all  i!,,.  ,,..,.  in  .acli  o.n4ilion  in.lir.iu. 
'.I'.it  ni  10, ,t  tlir  14  ra^r-  of  rirrlio.iv  tJnTc  w.i,  ,l,-lM,ilr 
"""■I":"al  minrv.  ,^  v,  it!,  1,..^  ni.arkrd  iiijnrv  an;]  onlv 
<'ni'  witli  ;i  i.ractirr.llv  norni;il  finuii.m  tliiun^'ji,  ,nt 
uliik'  III  rhr-oiiic-  pa-ivi-  conircsli.ui  oiilv  4  sltoww]  ijoli- 
nitr  .lo-iv.:.^,  ulnlr  7  sl„,v,ol  a  praoticillv  nomi.-.I 
lunction. 

/'■"■;'■'"""■■  "■''  /'••■■'.  I.ililo  ,lata  oniMMc  ,,f  ij„. 
l'iunoliur;irhior;,liili;ru^in  l,avr  hccii  oilkTU.l  C  _>N 
ulio  .K!liiiicK  ha.l  nirta^la>i.  to  tlic  !ivu-,-'  sl,„.,vi.l  a' 
-^  piT  rrut.  oiitpiil  ii\c  nioniiis  lii'forc  (K-ilh.  ||  _"  i 
wall  ,-:;i-iru-  carniioin.!  ;m4  rlinii-.aJlv  tlion!,4it  to  liivj 
uK't.iMaMs  to  tlu'  1m, r.  sliouol  :i  24  pu"  ru,l.  onlpnt 
plinio!tUr,ulilorplitli;ikin  p<,sitivc  in  nriiic  ami  tlic 
'"va  only  21  per  rent.  u{  ihv  tot.il  non-protein  nilro-c,, 
"•  '''"'"!■  llH'.-r  r.iM's  ;mx'  in  kcvpin-  uilii  tlio  tlim- 
'  a^i's  ot  luiT  r.irniioni.a  r.|H,rlc4  last  vr.ir  in  whirl) 
Hi^'  l4unoliai,u!;lnri,!iilialciii  r.xcRtion  u,is  S.  M  and 
/  I'll-  rnit..  rcvprniwlv.  NouH'vir.  a  sli-lit  .Kmcmm 
'n_  plunolntiMriilcpliili.iKi,,,   f,,,-  i,,m;, ,„.,._   ,•,,„„  jn  to 

-^  1"';  '■'"'  ''"^-^  ""'■  indirati'  livrr  .-aivinonia,  sinn- 
-iuli  tin,l,nc;.  li.iNc  Iktii  found  in  -.istric  caidnoni.i 
''''^'"  ""  I""'""  "I  li\''i-  nutasi.iMs  was  at  li.ind,  in 
uliicli  .Msr  ,1  ,.  iiinaK  ihr  I'xpia-ssinii  of  ilir  inllnrn,-, 
"I  ancniia  .uid  ca.luAi.i  on  li\ir  luiutioiK 


eoiin|[^';;j'M;^r /:i;:^c^?^,*"  '"""•' '"  ">'  "••'"  -  "•«  pro. 


'  >'-'^-  nMhc  .nnary  nilro^c:,  partition  ,,4;: 


/  ".•//<■    llrp.ititis.^A  )\     the 


Iwij    fast.,    sui,h\.,l_    ,,„^^, 


ti 

t(i|; 


'"     I'liHi'I,    ,111,1    |-|rmiii-<    111 


.vv,.,u.K    "1-  -v.uh.  or  u.luy  appluat,.,,,.  of  tlK- 
■'•'    "'  MMv-,r\r:i  palK'ni-  v.,.,v  rvp,,r!c-,l      Tlu.  „„.,i 
'".""Utoi  i.alinu-  Mu.liol  in  ,l.ac  is  IH    ihi        i 
;''whon,i,a,,nodnn.aK.M,,..„..,,r\,;;\,!        ;''■- 
l"'MtnMm<l„p,^lu.aI,han,l,„^anou.,vp.    ofli.,^ 


!'■  itvi.ir.  arv  .li,,\\;i   in   T,,],!.,  _ 

•^1'   l;o|'.-5\     ,    vsKs 


,1  -    T'^  ''^^■^■^'^^'^^•""'""urn.psv,  an,|patl,. 

;1"«K     nnjhp.s   .onirnv.ninK    thr    f„n,-,  „nal    hn  lin^s 

''■'''••Y'-;'^^'<■a■■c■.  ulmhdnnVaiivMvu.  ,l,o„.I,      , 

'•?;;'•  •"   '.'^■""!-^.   "•   l)..^c•  nu  nrrhoM-s  at 

F'F'™"Sf.M:;::,:"'i:;;;-:;;i;;;;r-;r'^;;;;- 


innimv   l.riwccn   ibc 


IG 


anatdiiiio  nml   functional    lindiny-   u\    iln-   plu'iKiUei'-a- 
elildrpiithalcin  tc>t. 


Ki  ;.\  n\i'  \  Ai.ri'^  of  ti-sts 

I  1k'  siTJi.-  (if  ca--r-  is  not  -ufliricntlv  larm-  In  draw 
lar-rrachin^  c(inchisi(in>  a-  to  llic  rcJalixc  valuer  of 
llic  ilifferviii  te.-t-.  liin  tlu'  following:  iniprc-sions  lia\r 
Iiicn  rccfiwil  : 

(I')  riH-noIiiir;,rlil,,ri'lHlKiK-in  :  A  plu'nnltctrai-lilor- 
]ihtliak-in  i.nipul  in  tin  |\cr-  \n]u\v  M)  ]kv  ccnl.  or  ii- 
aniicaianiT  in  liu-  nrinc  i^  infrr.|urnt  in  iiraltli  an.l 
fre-(|ncni.  in  .•niatoniicallx  .li-ca^cd  li\ci-.  A  normal 
outpnl  ilofs  nol  cxt'huli.'  Hmt  injnrv. 

' '' )  I'lhrinoLjAii  :  i.nw  valine  ar^'  fi\'<|MLiit  in  lir- 
rliosis.  Imt  inronstant.  \\i\  |,,\\  liiidin.--  may  ra.rr\ 
liro^n!o--tir  sio-iiilicau.'i.-. 


I  Ai'.M. 


I'liMIIM-.    l].\l>i\.,.s    l\    l||;Al.in    AM)    I\    M\lk 

i)(si.  Asi: 


' 

Kx.imiiieil 

\..n.i.-.ls     .... 

.1.1 

(■irrli.i>is     ....; 

IS 

('iinKCMiiiii     ..i 

iJ 

('.criiiiiiiii.i      of 

liviT      

b 

<';ircitiimi.-i      .  . ' 

5 

riKTic       liVLT.  . 

5 

'^t■\  t-rc  ;uicnii:i 

') 

Mio-ellnnemis. 

5 

Tut,-ils     .... 

11,< 

l.c's    Tli.m    .111  I'rinc 

IVr  (."ent.  Kx.iir.iiu'cl 


r...-.iiiiL- 


■) 

, , 

,t 

«^ 

11 

T 

1 

io 

6 

f, 

.^ 

2 

.^ 

^ 

■> 

2 

J 

1 

7 

1 

0 

■> 

1 

> 

2 

54 

2J 

(  .■  i  j.iiiavc:  I  )i  tciniinalion  of  lipolytic  anixiiv  of 
Moo. I  inriiislK'^  IJiMr  ,,y  n,,  in  !'(,nnaiio!i  ,,f  dianniistir 
or  proL;noviii-  \:;hu'  in  lla-c  Inoiv  ,,f  ca-cs. 

(  (/ I  r.ancr'-  '^ala.to-c  .and  Straii-s'  K-\ulo-c  tol- 
\  irldi'd  \v\\   liiilc  infi>rniation  in  ihi-  -eric-. 

(I'l  I 'r.  '  looilp.a-liirc"-  filirinolv  1  ic  I'crmcnt  -tiidio> 
<  :i  111!  Mric-  oi'  ca-c-  diow  that  ihi-  fcrnunl  i-  pres- 
ent iinl\  ill  liirlioH's  and  li^iicc  when  jirc-cnt  i-  of 
diaL;iio~lic   \alnc. 

I/)  JMOod  .\iiri';^cn  r.iriiiinn:  I 'n.i  niiromai  \\.a■^ 
low  in  siAcral  instance-  ,in.|  t -prci.dlv  low  in  ca-c--  of 
;i(!\aiiccil  cirrlio^i^.  Amino  .icul  miio-in  wa-  I  l^li  in 
a  con>iik'ralilc  pro)iorlioii  of  the  c;i-es. 

I '/ 1  I'rinaiv  Xiiro-en  I'.irliiion:  '{"lie  ammoni.i 
and    aniinoiiiiro-eii    were    increa-ed    in    nio-t    of    the 


11 

ia-f>  Muclicd,  iiariicul.iilv  in  cirrlioM:-.  (  (winjr  to  tlic 
iinn-fxclnsioii  (,f  acidosi-^  n.UMdcrahle  (liftiailty  is 
cxpeneiicol  in  interprftin-  tlic^e  result^,  li  would 
nave  I.LTii  advisal)lo  to  liavr  aUoniiJtod  In  exclude 
andov].   l,y  the   leedins.'  of  alk;dies. 


I'KACTK  .\i;lIJT\     of    TKST.s 

■/■//.■  plicuolictmchlorphthalcw  test  inv(jlv.e<  an  intra 
xeiiou-  mjeetion  and  careful  collection  ui  <\unU    f,,[- 
liH-ty-ei,t,dit    hours.       'J-liree    undesirahle     feature-    are 
omnected  xvuh  its  ai.plicalion  :     1.   T!ie  .[Ualitv  of  red 
colnr  ohtanied  ni  certain  instance-,  (  fmni   1(J  to  20  per 
cent.  „!   the  ca>e- )   is  such  that  accurate  (|uantitati\  e 
e-tiination  i>  dillicnlt.     (  )nlv   in   rare  instances  is  this 
a    -erious   ditilcuhy   leadin-   to   ermr   of   more   than    - 
P<-'r  cent.      2.   ThnmilMiHs    fre(|uentlv    follows   at    the 
P'Hiit  .,1   inieciK.n,  a,-  evidenced  hv  sri<,dil  local  pain  or 
lenoerne-s    to.^ether    with    re.>i-iance    o||\.,-,,vI    u;    the 
pali)atiii,<,r   tin.,rer  aloni,'  the  cur-e  of   the   vein       'Idiis 
"ccnrred  in  ei-ht  in-tances  in  tlii-  -eric-  ,.f  ca-es,  hut 
HI    no    ca>e    ha-    ii    occasioned    -eriou-    di-contfort    or 
resulted   in  actual   h.arni  to  the  palieni.      .v    With    -alt 
dilution   nia.le   with    ;re-hlv  distdk',!   xvaler  chills    fol- 
ln\vin.,r  the   injection   ;,re   infre<|uent.      When   no  <lilu- 
"""    1-    employed    chill-    are    le-s    ire(|ueni    and    not 
accom|iamed    wuh    increa-e   in   ieniperalu!  e. 

l-ihriu,uiru    (li'trnniiuilioiis   are    iuai.plicalile    in    the 
l-resence  oi  vc^^re  anemia,     'ihev  nece--ilate  the  wilh- 
drawal  ol    trom  40  to  50  c.c.  of  hlo,,,!       \  In^^l,  .peed 
<ontritn,-v    and    cousiderahle    chemical    e.|uipmeut    are 
requiMte-       Ihe  u-I   1-  time-con-uniinL:.      /.//-,/•:,■,/<•/<•;•■ 
onnatuiii..    re,|uirr    neither  cmplicaled   apparatn-    nor 
inuch    tmie.       / /,,•    ,lrtrnninati,:,i    „/     //„■    /„/.,/    „„;,. 
tnitriii  intnuicii.   ur.ui  iiitr,„/r„  and  awinn-acid  iiitro- 
<n-ii  ..t    the  hloo,|   cannot   he  carried   out    when   M-vore 
anemia    cxi-t-.        Technically    the    determiuali,,n-    are 
ea-y  hut  are  tlme-con-uminJ,^      l/u-  iiitro>,ni  pmtitiou 
tn   Ihe  urine  re.|Uire-  soniewiiat   le-.  time.      .laUulou- 
>an  he  adnnm-tered  without  di>coint'orl  k.  the  pilient 
hut  technical  dilliculties  attend  the  use  of  Iriid.'sr    at 
least  2s  per  lent    of  the  palicnt-  refn-intr  i,,  ,;i|^e  the 
mil  amount  or  .lexelopinir  nau-ea  or  \oiniliiii,r  fallow 
:n.-  its   mye-lioii.      / /,,•  fihnuolytir  frrmrnl  i-  re-i<iilv 
demon-trated.       I  ' r,'hilino,,n,    dclrnnuuUwns    m    the 
urine  are  \ahuK--  unle-s  made  dailv   f(,r  a  peri.,,]  of 
iv\o  ueek-  and  uiile-  a.-,,ci;ii,d   with   iirolMlm  deter- 
minations in  the  Icccs. 


12 


(I i.\i  i.rsicNS 

1.  <  iul-]i(ikcu  cli.in-c>  ill  lixcr  fuiKlinu  i  an  ho 
ik'iniiu^tr.-itcd  ill  iiH.^t  case-  of  advanced  liver  rir- 
rlici-i-,  ill  markedly  eon.i^cstcd  livers  a-suciated  with 
iii_\(ica.rdia!  iiiHirficieiu-y.  in  earciiKniia  of  tlic  liver,  in 
luetic-  liwTv  and  in  conditions  of  cachexia  with  marked 
.■meiiiia. 

-'.  i-niictioiial  cliano-ev  have  heen  mo.-l  marked  in 
cirrhdM-,  neoplasm  of  the  li\er  and  in  cachectic  coii- 
(hlinii^  a^M.ciated  with  severe  .i^rade^  of  anemia, 
l-nnclioiial  clian<;e-  in  chronic  jja^-ive  collie-lion  have 
not  heen   li\'<|Uem  iw  pronounced. 

.\  ll.aniiiiiiy  in  the  lindiiiL;-.  of  the  te-l>  i-  ])re>.ent 
ni  Miiiie  ca-e-,  that  i-.  most  of  the  le-t-  indicatin,L[ 
either  a  dtcre,i-e  function  (jr  a  norin;d  funclioi'r 
However,  lack  of  harmony  i-  strikiiiL;   in  other  cases. 

4.  (  oi.cermuL;  the  relative  merits  of  these  te-ts  the 
ii'il"''---!""-  lli'il  li;i\c  heen  received  are  thai  the 
deiernniiation  of  the  phenoltelraclilor].luhalein  excre- 
•i""-  llii.'  iihrino-en,  ,\nd  the  nitrogen  iiariitioii  in  the 
hlood  and  urine  are  of  decidcl  v.dne  in  revealin-  the 
pre-ence  oi.  and  t(i  a  le--  dci^rte  the  extent  of,  fniic- 
tional  involvuiienl,  while  ihe  deiiion-lration  of  ;i 
lihrinolviic  feniieni  i.  ef  di  cided  di;i,,Mio>tio  inipor- 
t.iuce.  Ihe  deiermin.atiiui  of  the  -u,L,'ar  lolenmce  ;md 
ollhe  li)iolyiic  ,:ciivjiy  ,,f  the  hlood  ;ipp,irentl V  alYord 
iulormaiiuii  i,{  mmh  ie--  v.aluc. 

Ihe  iniiirmatii'ii  derived  frtiiii  ihe-e  -tudies  on  the 
''\'-''"  'l'";'^  Hot  coiii]',ire  in  di.ai;ii(.-iic  and  pro,t;no-tic 
v.dne  wi;h  th.it  dei-iveil  from  c.  irre-pondin.L,''  -tudies 
ol  the  kidney.  I'hi-  in;iy  d.epeiiil  (,n  -everal  factors, 
n.inielv.  (  ,;  i  the  iii;ide(|u;icv  of  our  knowledge  of  liver 
pliv -ioioi^v  ;  I /' I  till'  liniili'(|  iiumher  (d"  ca-es  ;tnd  of 
type-  (it  -evcre  liver  injurv  under  ol)-erv  itioii  ;  (  <■ ) 
the  ]io--ihle  e\i-tence  of  ;i  <;real  "'f.-K'tor  of  -afety"  in 
the  liver,  vvherehv  in  ca-e  of  iiece-div  function  is  car- 
ried on  ehicieiiilv  hv  a  relatively  -m.-dl  projiortion  of 
hvcr  MihM.iiuc:  ill)  the  f,-ict  th;it  the  iiroL;no-is  in 
m.iuv  i'\  the-e  ca-e-  i-  controlled  hv  factor-  other 
than  decrc.i-ed  liver  function,  .ainl  (  (•  )  the  l;icl-;  .it  pre-- 
eiit  ot  correl.iii'.n  ol  ;m;!toniic.  clinic.-d  .anil  functional 
lindiiiL;-  occ.a-idnr  1  hy  the  newnes-  of  the  -uh]ect.  The 
re-ult-,  however,  enconr.i-e  u-  in  the  helief  th.at  -cien- 
tilicallv  ,ind  ;d-o  clinicdlv  thi-  -uhject  i-  worthy  of 
e.Meiisive  inv  e-tiijation. 


1 


